Application Form

Application Form

Please take your time as incomplete forms will delay your application.
What position are you applying for?*
How did you hear about the vacancy?
Date available from?*

DayMonthYear
Key in numbers, or choose from calendar
Salary expected?
i. Personal details

Tell us about you.
1. Name*
Address - please provide last 5 year history.*

Country
2. Date from*

DayMonthYear
Key in numbers, or choose from calendar
3. Date to*

DayMonthYear
Key in numbers, or choose from calendar
4. Have you lived here for 5 years, or more?*

YesNo
4a. Previous Address

Country
4b. Date from

DayMonthYear
Key in numbers, or choose from calendar
4c. Date to

DayMonthYear
Key in numbers, or choose from calendar
4d. Add another address?

YesNo
4e. Previous Address 2

Country
4f. Date from

DayMonthYear
Key in numbers, or choose from calendar
4g Date to

DayMonthYear
Key in numbers, or choose from calendar
5. Date of birth*

DayMonthYear
Key in numbers, or choose from calendar
6. Phone Number*
Please enter a valid phone number.
7. Email*
example@example.com
8. Nationality*
9. National insurance number*
10. Do you hold a current full UK driving licence?*

YesNo
11. Do you own, or have regular use of, a vehicle?*

YesNo
ii. DBS questions
12. Mothers maiden name*
13. Town of birth*
14. Have you been known by any other names?*

YesNo
14a. Previous name*
14b. Date name changed*

DayMonthYear
Date
15. Country of birth
iii. Next of Kin details

Tell us who to contact in an emergency.
16. Name*
17. Phone Number*
Please enter a valid phone number.
18. Relationship to you
19. Address
iv. Disclosure of Criminal Convictions (Unspent)

Please read and complete carefully.
It is the policy of SureCare Bolton to require all applicants to disclose any unspent criminal convictions, cautions, reprimands or any other warnings.

You are required to include convictions, which may be “unspent” under the Rehabilitation of Offenders Act 1974. This is because the job you are applying for is covered by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 and 1986. “Unspent” criminal convictions must therefore be disclosed.

The information you provide will be treated as strictly confidential and will be considered for appointment for which you are applying. The Disclosure & Barring Service will show anything which the Chief Constable feels may be relevant.

Disclosure of any information does not necessarily mean that you will not be considered for appointment. The Company will have regard to the ACAS Code of Guidance and a main consideration will be whether the offence if one which would make an applicant unsuitable for the type of work to be done.

Enter any information in the space provided. If you have no information that you believe is relevant, please enter “None”.
20. Do you have any unspent criminal convictions, cautions, reprimands or any other warnings.*

YesNo
20a. If yes, please provide details here: date, what happened, and outcome (caution, conviction, or none)
v. Education
21. Please enter the most recent first*
vi. Employment history

Tell us what you have been doing.
22. Please scroll to the right to see all fields and start with the most recent employment*
vii. Health details

Provided in confidence
23. GP / Doctors name*
23a. Surgery Address
23b. Surgery telephone*
Please enter a valid phone number.
23c. May we contact your GP?*

YesNo
24. Have you, within the past three years, had any illness or accident which caused you to be off work for two weeks or more?*

YesNo
24a. Please provide details:
What was the illness, or accident?
24b. How many days sick leave have you had in the last 3 years?*
25. Have you ever been medically examined for employment before?*

YesNo
25a. Please provide details:
26. Immunisation history*

BCGTetanusPolioHepatitis BRubellaFlu (Current year)None
26a. Covid 19 Vaccination*

1st DoseBooster2nd DoseNone
27. Have you ever had a chest x-ray?*

YesNo
27a. When and where?
28. Have you within the past year, attended an out-patients clinic or had a course of treatment (tablets, injections or physiotherapy) lasting one month or more?*

YesNo
28a. Please provide details:
29. Are you attending hospital or your GP or receiving any medical treatment at present?*

YesNo
29a. Please provide details:
30. Are you pregnant? (We need to know this so that can take steps to protect you and your baby)*

YesNoN/A
31. Do you smoke, or drink, alcohol?*

YesNo
31a. Cigarettes per day:
31b. Units of alcohol per week:
32. Have you any permanent disability?*

YesNo
33. Are you a Registered Disabled Person?*

YesNo
33a. What is your disability?
33b. What is your registered number?
viii. Health history

Are you suffering from or have you ever suffered from:
34a. Fits, epilepsy or black-outs?*

YesNo
34b. Diabetes?*

YesNo
34c. Tuberculosis (TB) or close contact with anyonesuffering from TB?*

YesNo
34d. Depressive illness, mental or nervous trouble? (Including anorexia nervosa, bulimia or overdose)*

YesNo
34e. Such diseases as typhoid, cholera, hepatitis?*

YesNo
34f. Skin disease or problems such as eczema, psoriasis, or dermatitis?*

YesNo
34g. Allergy (to any drugs or to handling any substance)?*

YesNo
34h. Earache, or ear infection discharge, or defect?*

YesNo
34i. Colour blindness, chromic eye trouble, eye injury or visual defect not corrected by glasses or contact lenses?*

YesNo
34j. Tonsillitis, sinusitis, frequent sore throats, colds?*

YesNo
34k. Heart/circulatory trouble. Raised blood pressure?*

YesNo
34l. Lung or chest complaint (e.g. asthma, bronchitis, pleurisy)?*

YesNo
34m. Bowel disorders, diarrhoea or constipation?*

YesNo
34n. Bladder, or kidney problems?*

YesNo
34o. Varicose veins?*

YesNo
34p. Problems with your back, or neck?*

YesNo
34.q Hernia, or rupture?*

YesNo
35. If you have answered 'yes' to any of the above health questions, please give details below:
36. Have you ever been refused employment, or dismissed on medical grounds?*

YesNo
36a. Please provide details:
The answers supplied to the above questions are true to the best of my knowledge. Furthermore, I undertake, if appointed, to report immediately to my Manager if I, or a member of my household, should be suffering from Covid19 symptoms, vomiting, diarrhoea, skin rash, septic skin lesions or discharges from ear, eye nose or any other site.

1. After returning to, but before re-starting work, after any of the above illnesses, and

2. After returning from a holiday abroad, having suffered from vomiting and diarrhoea for more than two days.

I understand that when deciding to appoint or not appoint me, SureCare will only take account of any medical conditions I may have where the medical condition contraindicates the type of work applied for, and where reasonable adjustments to accommodate my medical condition cannot be made.
37. Signature*

Clear
37a. Date*

DayMonthYear
Date of signature
37b. Print name*
Permits and References
ix. Non British and Non EC Nationals
38. Is a work permit required?*

YesNo
Please ensure this is provided along with your other documents. Failure to do so will delay your start date.
References

Please provide 2 professional references. By providing this information you consent to SureCare contacting them to request information.
39. Referee 1*

Please include job title also, if employer
39a. Email*
example@example.com
39b. Phone Number*
Please enter a valid phone number.
39c. Address

Employers name (for work reference)

Employer address (for work reference)

State / Province
40. Referee 2*

Please include job title also, if employer
40a. Email*
example@example.com
40b. Phone Number*
Please enter a valid phone number.
40c. Address

Employers name (for work reference)

Employers address (for work reference)

State / Province
41. Add another reference? (if the first two are not both employer/professional)

YesNo
41a. Referee 3*

Type of reference
41b. Email*
example@example.com
41c. Phone Number*
Please enter a valid phone number.
41d. Address

State / Province
41e. Add another reference? (if the first two are not both employer)

YesNo
41f.Referee 4*

Type of reference
41g. Email*
example@example.com
41h. Phone Number*
Please enter a valid phone number.
41i. Address

Employers name (for work reference)

Employers address (for work reference)

State / Province
42. Details of skills/experience
Declaration

I confirm that I have completed, read, and understood this document.

I understand that the completion of this form does not guarantee employment.

I certify that all the information given on this form is true and accept that any mis-statement or suppression of material may mean the cancellation of any appointment, and the termination of any employment.

I understand that any offer of employment made is subject to the receipt of satisfactory references, successful completion of training, and an Enhanced Disclosure and Barring Service Check.

I confirm that SureCare have my consent to seek references from the above given referees.

I understand that SureCare is an Equal Opportunities employer and that an offending record or medical condition is not necessarily a bar to employment.

As this post is exempt from the provisions of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975, I hereby undertake to advise SureCare of any criminal offence which I may be convicted of during my employment with SureCare.

The Working Time Regulations 1998 govern the length of the maximum working week which it is safe to work. The current limit is 48 hours per week. You will never be compelled to work more than 48 hours per week but you may choose to do so if you wish.

I have understood the information regarding the Working Time Regulations 1998 and I understand that I do not have to work more than 48 hours per week.
In compliance with Data Protection and the General Data Protection Regulations:

SureCare will only collect information for the purpose for which it is intended Personal data shall be processed lawfully, fairly and in a transparent manner in relation to the individual. It will only be collected for specified, explicit and legitimate purposes and not further processed in a manner that is incompatible with those purposes. The information will be adequate, relevant and limited to what is necessary in relation to the purposes of the SureCare business. All data processed will be accurate and, where necessary, kept up to date, every reasonable step must be taken to ensure that any personal data that is identified as inaccurate, having regard to the purposes for which they are processed, are erased or rectified without delay.

Any identifiable information stored about you as an individual will be relevant and stored for no longer than is necessary for the purposes for which the personal data is processed. Personal data will only be stored for longer periods to ensure compliance with the requirements under the Health and Social Care Act 2008 Regulations 2014 and subject to implementation of the appropriate technical and organisational measures required by the GDPR in order to safeguard the rights and freedoms of the data subject.

SureCare will process data in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures The information which you have supplied on this form will be processed and may be held on computer, and will be held on your personal records file if you are appointed. The information will also be used for equality monitoring and statistical purposes. By signing this application, you will be deemed to have given your consent to this, including information which may be considered to be sensitive and personal.
43. Signature*

Clear
43a. Date*

DayMonthYear
Signature date
43b. Print name*
Please verify that you are human*
Should be Empty:

Application Form

i. Personal details

ii. DBS questions

iii. Next of Kin details

iv. Disclosure of Criminal Convictions (Unspent)

v. Education

vi. Employment history

vii. Health details

viii. Health history

Permits and References

ix. Non British and Non EC Nationals

References